• Retinal Detachment in Children With Self-Injurious Behavior

    On Friday, at Retina Subspecialty Day, Yoshihiro Yonekawa, MD, discussed the management of retinal detachment (RD) in children with self-injurious behavior. These patients are “the most complex patients you’ll encounter as a retina surgeon,” he remarked, “but [this is] something we never talk about.”

    Management dilemma. Children with severe autism or developmental delays often display self-injurious behavior—face slapping, head banging, or vigorous eye rubbing. Such cases, Dr. Yonekawa pointed out, require different pre-, intra- and postoperative considerations. The usual treatments for severe proliferative vitreoretinopathy (PVR) or multiple breaks are not always viable options, he explained. These children cannot always use postoperative drops, and it is not easy to position them, to check intraocular pressure, or to examine them postoperatively. Since self-injurious behavior may continue after treatment, these patients also require durable options.

    “Do we know how we should be treating these very complex and very vulnerable patients with severe retinal detachments, where many of the usual surgical rules don’t apply?” asked Dr. Yonekawa.

    Study design. Searching for the answer, he collaborated with an international community of pediatric retinal surgeons to perform a multicenter retrospective study; Elizabeth Rossin, MD, PhD, spearheaded the data analysis.

    They followed 76 patients for an average of 3.4 years. Patients exhibited self-injurious behavior for 4.7 years and often presented with changes in visual behavior (42%) or eye appearance (16%). Initial treatment for these eyes varied and included scleral buckle, vitrectomy, and buckle-vitrectomy; 18% were deemed inoperable.

    “Some of the worst outcomes in our field.” According to Dr. Yonekawa, the success rate after a single surgery was 22%; the odds improved if the patients were treated with a buckle, but there are confounding variables. The final reattachment was 36%. Adjusting the outcome to accept retinal detachments under oil improved the success rate, but numbers were still low, said Dr. Yonekawa. Reattachment correlated with use of scleral buckle, no funnel configuration, and a lower grade of PVR.

    What about the fellow eye? Fellow eyes that presented with retinal tears without detachment generally did not develop RD if they were fully lasered or prophylactically buckled; however, the retina of one eye detached after initial presentation with a dense cataract. None of the five eyes with prophylactic buckles experienced RD during the study.

    “Anecdotally, we note one case that didn’t make it into the study that detached after buckle,” said Dr. Yonekawa, “so it’s still not perfect but I think it’s something we can consider.”

    When managing patients, he urged surgeons to work with other physicians and therapists. “I think these patients are a good reminder to us that we have the eye in front of us, but we have to take the entire patient into consideration—their social issues, behavioral issues—to think of the best management plan to optimize outcomes in these vulnerable patients,” Dr. Yonekawa concluded. —Kanaga Rajan, PhD

    Read more news from AAO 2019 and the Subspecialty Day meetings.